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Every Patient Must Have Individualized Patient Assessment Individualized Plan of Care By Interdisciplinary Team Done Timely Implemented Reviewed and Updated as Indicated

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4 Who Is Needs to Be Involved? IDT includes at a minimum: The patient or their designee (if the patient chooses) A registered nurse A physician treating the patient for ESRD A social worker A dietitian

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When Must POC Be Implemented? First assessment: within the same timeframe as the assessment (latter of 30 days/13 treatments) Any reassessment: 15 days after reassessment completed

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9 What About Stable Patients? If a “stable” patient’s outcomes do not meet the care plan goals in an area, the facility must recognize and address that aspect and revise the plan of care accordingly between annual comprehensive reassessments “Monitor, Recognize and Address”

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Take It To the MAT Measures Assessment Tool Current, professionally accepted clinical practice standards of care at your fingertips Common understanding of expected targets/goals Let’s take a look at the MAT…

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11 What Do You Need to Document? Process for patient assessment Patient plan of care development Goals Timelines Plan of care implementation Plan of care review/revision

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Now to Let You Do Some Work! In order for you to demonstrate knowledge of the link between the patient assessment and the plan of care for that specific patient, and To identify critical components of the POC for specific patients, We have created several case studies for your “IDT” to use in developing or updating POCs…

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Pitfalls to Effective PA/POC Doing great assessments; not doing a plan of care Not using the information gathered in the assessment to develop the POC Not implementing the plan Not reviewing the results to see if the plan is working Not updating the plan to change or refocus the goal(s) Not monitoring the individual’s progress after interventions are implemented